Heritage Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 9500 Grand River Ave, Detroit, Michigan 48204
- CMS Provider Number
- 235234
- Inspections on file
- 32
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Heritage Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions reported a returned check despite believing they had sufficient funds. When the BOM assisted with reviewing finances, the resident’s wallet was found in a social service employee’s desk and the bank card was missing. Speakerphone calls with the bank, overheard by the BOM and an LPN, revealed a large credit card payment from the resident’s account that caused an overdraft and numerous disputed transactions at various retailers, gas stations, and an airline. Bank staff indicated they had been tracking the involved employee for a cash advance with invalid data, and the resident’s report of missing property and unauthorized charges met the facility’s own definition and indicators of misappropriation of resident property.
A resident with multiple chronic conditions and intact cognition had a check to the facility returned for insufficient funds, prompting the BOM to review the resident’s finances. The resident believed there was sufficient money in the account, did not have their bank card or wallet, and stated that the social worker had it. The BOM found the resident’s wallet in the social service office without the bank card, and during a call with the bank learned of large credit card payments and transactions the resident did not recognize, then identified a social service employee as a possible user of the card. Although the facility’s policy required prompt reporting of all alleged violations to the Administrator and State Agency, the BOM, who knew the NHA was the abuse coordinator, reported the concern only to the company’s owner and did not notify the abuse coordinator or State Agency within the required timeframe.
A resident with intact cognition and multiple medical diagnoses discovered that a check to the facility had bounced despite believing there were sufficient funds, and reported that their bank card and wallet were held by a social service employee. The Business Office Manager retrieved the wallet from a social services desk, noted the bank card was missing, and participated in speakerphone calls with the bank, during which large, disputed transactions and an overdraft-causing payment were disclosed, and the bank linked suspicious activity to the staff member holding the card. An MDS Coordinator/LPN overheard these calls, recognized that someone was stealing from the resident, but was never interviewed, and no statement was obtained. The facility’s investigation file lacked this witness interview and did not include an interview with the implicated staff member, resulting in an incomplete investigation that did not meet the facility’s abuse, neglect, and exploitation policy requirements.
A resident with schizoaffective disorder, dementia, and no prior eye disease was in a wheelchair in a hallway when a housekeeping manager repeatedly sprayed a Clorox bleach cleaner directly into the resident’s face while a housekeeper held the wheelchair in place. A CNA witness reported the manager made a threatening statement and then sprayed more bleach, recognizing the product by its bleach odor. The resident later reported that staff sprayed a chemical in his eyes and that his right eye remained painful. Medical records documented evaluation for eye pain and chemical exposure, with findings of epithelial irritation, corneal haze, conjunctival redness, periorbital puffiness, and chemical damage to the front of the eyes, attributed to the chemical exposure during the confrontation with staff.
A CNA exploited a resident with moderate cognitive impairment by using the resident's debit card to make unauthorized purchases totaling $1,900. The incident was discovered after a declined payment attempt, and the CNA admitted to the misuse before resigning. The resident, who had multiple medical conditions, suffered a significant financial loss as a result.
Surveyors identified multiple sanitation and maintenance deficiencies in the food service area, including excessive sanitizer concentration, soiled and corroded equipment such as the ice machine and can opener, and a broken microwave handle. These issues affected 107 residents who consume food products, and record review indicated a gap between facility policy and actual practice.
The facility did not effectively clean and maintain key areas, as evidenced by heavily soiled PTAC unit filters and dining room floors, as well as recurring flooding in the kitchen floor drain. Housekeeping staffing levels and maintenance practices were insufficient to prevent the accumulation of dirt, dust, and food residue, and to address ongoing wastewater issues, resulting in an environment that was not consistently safe, sanitary, or comfortable for residents, staff, and the public.
A resident with paraplegia and a recent surgical repair was transferred to another LTC facility without complete transfer or discharge documentation. The electronic health record lacked a transfer form, discharge plan, and summary note, and interviews with the DON and NHA confirmed that required information was not provided to the receiving provider, contrary to facility policy.
The facility failed to maintain accurate records for controlled drugs in its back-up box, leading to discrepancies in narcotic counts. The DON could not explain the reconciliation process, and the pharmacist confirmed discrepancies between the expected and actual narcotic counts. This failure to adhere to the facility's Pharmacy Services policy resulted in potential drug diversion and unavailability of medications for residents.
The facility failed to address MRR recommendations timely for two residents, leading to the continuation of unnecessary medications. A pharmacist's recommendations to adjust insulin and Xanax regimens were not reviewed or acted upon by the physician within the expected timeframe, as acknowledged by the DON.
A resident with a history of stroke and a ruptured right eye received only two doses of prescribed erythromycin ophthalmic solution instead of the full 14-day course due to a transcription error in the MAR. This error resulted in the potential for prolonged symptoms of a right eye infection. The DON confirmed the transcription mistake, acknowledging the resident should have received the medication for 14 days.
A facility failed to maintain an accurate Antibiotic Stewardship Program, leading to a resident's antibiotic prescription for an eye infection not being documented or monitored. The resident was prescribed Erythromycin ophthalmic solution for 14 days but only received two doses. The Infection Control Nurse was unaware of the prescription, and the oversight was attributed to the resident not being listed on the infection report log.
The facility failed to properly screen, educate, offer, and document influenza vaccinations for several residents, resulting in incomplete and invalid consent forms. One resident consented to the vaccine but did not receive it, and others were not properly offered the vaccine, despite the facility's policy requiring annual vaccination offers and education.
The facility failed to maintain cleanliness and repair on multiple floors, affecting residents' living conditions. Observations included cracked floor tiles, broken equipment, and persistent odors on the third floor, while the fifth and second floors had issues like non-working elevator lights, urine odors, and damaged wheelchairs. Interviews revealed a lack of effective monitoring and an incomplete maintenance checklist.
A facility failed to follow medication administration standards, including not priming an insulin pen, improperly administering medications through a PEG tube, and a transcription error in a resident's medication record. An LPN did not prime an insulin pen before use, administered multiple medications through a PEG tube without individual flushing, and a transcription error led to a delay in correcting a resident's medication dosage.
The facility failed to provide adequate grooming and hygiene care for three residents, resulting in unmet hygiene needs and emotional distress. One resident had unkempt, matted hair with lint, another had tangled hair in a knotted ponytail, and a third had a visible beard and soiled clothing. Staff interviews revealed confusion about grooming responsibilities, with no requests made for grooming services on the third floor.
A resident with a supra-pubic catheter experienced discomfort and potential risks due to inadequate catheter care. Observations showed the catheter tubing was taut and not properly secured, with the collection bag often at the bladder level. The resident reported discomfort and a history of catheter dislodgment. Staff interviews revealed inconsistent care practices, and the resident's care plan instructions were not consistently followed.
A facility failed to justify the use of a PRN antianxiety medication, Xanax, for a resident with a history of stroke and depression. The resident's prescription lacked a 14-day stop date and documentation for continued use. Staff interviews revealed that the oversight was missed by the visiting psychiatry group responsible for monitoring psychotropic medications.
A facility failed to ensure proper communication and documentation of hospice services for a resident with severe cognitive impairment, resulting in a lack of coordinated care. The hospice logbook lacked nursing notes, hindering effective communication with hospice staff. The Corporate Consultant confirmed missing notes, which should have been in the resident's EMR. The DON acknowledged the issue but could not explain how coordination was possible without the nurse's documentation.
The facility failed to implement enhanced barrier precautions for two residents, leading to potential transmission of infectious organisms. Staff provided care without PPE, despite residents having conditions like stage IV pressure ulcers and bacterial conjunctivitis. Interviews revealed a lack of adherence to PPE protocols, despite staff training.
The call light system on the third floor of the facility was not functioning, leading residents to use bells for assistance. An irate resident had damaged the main box, causing the malfunction. Residents reported difficulties in getting help as nurses might not hear the bells. The facility had an undated estimate for repairs but no signed contract or timeline for completion.
The facility failed to update care plans for two residents after multiple falls, despite their impaired cognition and need for assistance with mobility. One resident's care plan had not been updated since 2023, and another had outdated and incomplete interventions. The DON acknowledged the need for updates per the facility's policy.
A resident with impaired cognition and mobility issues did not receive a concave mattress as specified in their fall care plan. The DON confirmed the use of a regular mattress instead, contrary to the care plan's intervention for fall prevention.
The facility failed to monitor the weights and nutritional status of two residents who refused to be weighed, resulting in significant weight changes going undetected. One resident experienced a 16.3% weight loss over two months, while another had a 14.6% weight gain. Nutritional assessments and care plans were not updated or revised as required, and the facility did not notify physicians or use alternative assessment tools.
A hospice resident with a history of stroke was found unresponsive on the floor with a pool of blood around the head due to the facility's failure to implement fall prevention measures and provide adequate staffing. Despite being assessed as 'not at risk' for falls, the resident's care plan lacked fall prevention interventions, and a floor mat was not in place. Staffing shortages further contributed to inadequate supervision, as the night shift LPN had to manage two floors with only one aide, impacting the ability to monitor the resident effectively.
The facility failed to maintain a functional call system, affecting residents in specific rooms and shower areas. Observations revealed missing call light panels and non-functional alerts, with some residents unable to use their call lights for weeks or months. Despite requests, the facility did not provide audit logs, and maintenance issues were not promptly addressed.
The facility failed to maintain a safe, clean, and comfortable environment, with issues such as missing elevator handrails, gnats in rooms, and unresolved maintenance concerns like non-functional showers and broken blinds. Maintenance logs showed numerous unresolved entries, and staff interviews revealed a breakdown in the process for addressing these issues.
The facility failed to consistently assist the Resident Council in organizing monthly meetings and addressing concerns. Complaints included long call light wait times and insufficient seating during meetings. The facility lacked meeting minutes and follow-up documentation from November 2023 to April 2024, despite having a policy supporting resident group organization.
The facility failed to promptly and thoroughly investigate allegations of abuse and neglect, including an injury of unknown origin for a hospice patient found unresponsive with a serious head injury. The investigation was delayed, incomplete, and submitted late to the State Agency. Additionally, other incidents involving allegations of abuse between residents were not promptly investigated, violating the facility's policy and regulatory requirements.
Two residents expressed grievances that were not followed up by the facility, leading to frustration and communication issues. One resident reported missing personal belongings, while another had concerns about call light wait times and medication administration. The facility's grievance policy requires prompt resolution, but no grievance forms or follow-up evidence were provided.
A hospice patient was found unresponsive with a head injury of unknown origin, but the incident was reported to the State Agency two days late. The facility's policy requires immediate reporting of such incidents, but the Nursing Home Administrator was not informed in a timely manner, leading to a delay in reporting.
Failure to Safeguard Resident Funds from Misappropriation by Staff
Penalty
Summary
The facility failed to protect a resident’s money from misappropriation when a social service employee maintained possession of the resident’s wallet and bank card and the resident’s funds were used for unauthorized transactions. The resident, who had diagnoses including epilepsy, congestive heart failure, depressive disorder, and anxiety disorder, but was documented as cognitively intact on the MDS, reported having over $4000 in their checking account after being notified that a check written to the facility had been returned for insufficient funds. When the Business Office Manager (BOM) assisted the resident in reviewing their finances, it was discovered that the resident did not have their bank card or wallet in their possession and stated that the social service employee had it. The BOM located the wallet in the social service employee’s desk, and when the wallet was returned to the resident, the bank card was missing. With the BOM present, the resident contacted their financial institutions via speakerphone and granted permission for the BOM to participate in the calls. Bank staff reported that the resident’s credit card payment in the amount of $6303.17 had been made from the resident’s account, causing an overdraft and resulting in the returned check. The bank also listed multiple transactions on the resident’s bank card with various retailers, gas stations, and an airline that the resident disputed. During these calls, the financial institution indicated they had been tracking the social service employee for a cash advance with invalid data. Another staff member, the MDS Coordinator/LPN, overheard the speakerphone conversations and understood that someone was stealing from the resident. The facility’s own abuse, neglect, and exploitation policy defined misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent and identified resident reports of theft or missing property as possible indicators of abuse, which were present in this situation.
Failure to Timely Report Suspected Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely reporting of an allegation of misappropriation of resident property to the State Agency and to the facility’s abuse coordinator. A resident with diagnoses including epilepsy, congestive heart failure, depressive disorder, and anxiety disorder, and documented as cognitively intact, had written a check to the facility that was returned for insufficient funds. The Business Office Manager (BOM) received notice of the returned check and, upon speaking with the resident, learned the resident believed there was over $4,000 in the account and did not have their bank card or wallet, stating that the social worker had it. The BOM then located the resident’s wallet in the social service office, but the bank card was missing. During a speakerphone call with the bank, the BOM and resident were informed that the resident’s credit card payment had overdrawn the account and that there were several transactions the resident did not recognize. The bank asked if they knew who might be using the card, and the BOM identified a social service employee, with the bank indicating that this person had been tracked for a cash advance with invalid data. Despite suspecting fraudulent activity toward the resident on the date the returned check was identified, the BOM did not report the suspected misappropriation of resident property to the facility’s abuse coordinator, who was the Nursing Home Administrator (NHA), and did not report the allegation to the State Agency. Instead, the BOM contacted the company’s owner by text and later by phone to discuss the suspected misappropriation. The NHA, who later reported the allegation to the State Agency, stated that the BOM was aware of the possibility of misappropriation when the check was returned and acknowledged that the BOM should not have bypassed the abuse coordinator. The facility’s written abuse, neglect, and exploitation policy required reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes, including not later than 24 hours for events that do not involve abuse and do not result in serious bodily injury. The BOM acknowledged awareness of the abuse policy and that they did not follow protocol when they failed to report the suspected misappropriation as required.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of misappropriation of resident property involving one resident. The Nursing Home Administrator (NHA) was informed by the corporate office that a social service employee (SSE M) was suspected of stealing money from a resident after a check written to the facility was returned for insufficient funds. The Business Office Manager (BOM G) spoke with the resident, who reported having over $4000 in the bank but did not have their bank card or wallet, stating that the social worker had it. BOM G went to the social services office and learned from Social Worker K that SSE M had the resident’s wallet in their desk. When the wallet was returned and reviewed with the resident, the bank card was missing. During a speakerphone call with the financial institution, in the presence of BOM G, the bank reported that the resident’s credit card balance had been paid off with a large payment that overdrew the account and listed transactions the resident disputed; the bank also indicated they had been tracking SSE M for a cash advance with invalid data. The resident, who had intact cognition per a recent MDS and diagnoses including epilepsy, congestive heart failure, depressive disorder, and anxiety disorder, expressed awareness that someone had allegedly stolen their money and suspected the social worker. The investigation conducted by the facility was incomplete and did not follow its own written abuse, neglect, and exploitation policy requiring identification and interviews of all involved persons and witnesses. Although the MDS Coordinator/LPN N was present in the office during the speakerphone calls with the financial institutions, overheard the details of the disputed transactions, and recognized that someone was stealing from the resident, LPN N was never interviewed and did not provide a statement because they were not asked. The facility’s Facility Reported Incident (FRI) file lacked any interview or statement from this witness. SSE M, who had been in possession of the resident’s bank card, was not interviewed because they resigned, and the FRI ultimately documented the allegation of abuse as inconclusive. This failure to interview all individuals with knowledge of the events and to fully document their accounts constituted a failure to conduct a complete and thorough investigation of the alleged misappropriation of resident property.
Failure to Protect a Resident From Chemical Spray Abuse by Housekeeping Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and mental abuse by housekeeping staff. Video evidence from the facility showed the Housekeeping Manager spraying a bottle identified by the Nursing Home Administrator as Clorox bleach cleaner directly at the resident’s face in a sixth-floor hallway, with approximately five sprays observed. During this incident, a housekeeper was seen holding the resident’s wheelchair in place while the Housekeeping Manager sprayed the chemical. A CNA who witnessed the event reported that the Housekeeping Manager stated, "I'm gonna fuck him up" and then sprayed more bleach cleaner into the resident’s face, and the CNA recognized the product as bleach spray by its smell. The resident involved had diagnoses including schizoaffective disorder, dementia, acquired absence of the left leg below the knee, and asthma, and was wheelchair-bound with moderate cognitive impairment. Prior documentation indicated the resident had adequate vision, did not wear corrective lenses, and had no history of eye disease or corneal haze, aside from dry eyes. A practitioner exam earlier in the month documented normal eye findings with white conjunctiva and non-icteric sclera, and the DON confirmed there were no prior eye consultations or documented eye conditions beyond dry eyes. Following the incident, the resident reported that staff sprayed a chemical in his eyes, that his right eye remained painful and "messed up," and that he had been treated at a hospital. Hospital and ophthalmology records documented evaluation for eye pain and chemical exposure of the eyes, with findings of significant epithelial irritation, corneal haze that was improving, mild conjunctival redness, and periorbital puffiness. The ophthalmology consultation diagnosed chemical exposure of the eye with chemical damage to the front of the eyes, noted as improving, and specified there was no limbal ischemia. These findings were directly linked in the medical record to the allegation of chemical exposure during a confrontation between the resident and a facility staff member.
CNA Exploits Resident's Debit Card for Unauthorized Purchases
Penalty
Summary
A certified nursing assistant (CNA) used a resident's debit card to make unauthorized purchases totaling $1,900, constituting exploitation and misappropriation of resident property. The incident was discovered when the facility attempted to process a payment with the resident's debit card, which was declined. The resident, who was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 12 out of 15, confirmed the incident during an interview. The CNA admitted to obtaining the debit card number and making the purchases, later acknowledging the violation of facility rules and resigning. The facility's policy prohibits abuse, neglect, exploitation, and misappropriation of resident property, defining exploitation as taking advantage of a resident for personal gain. Despite this policy, the CNA was able to access and use the resident's financial information. The resident had a medical history including hypertension, fractures, protein malnutrition, and physical disability, and was admitted to the facility with these diagnoses. The incident resulted in a significant financial loss for the resident, with only partial recovery of the funds at the time of the report.
Deficient Sanitation and Equipment Maintenance in Food Service Area
Penalty
Summary
Surveyors observed multiple failures in the facility's food service area related to cleaning and maintenance of equipment, directly impacting the sanitary conditions for 107 residents who consume food products. During a comprehensive tour, the sanitizer basin of the 3-compartment sink was found to have a quaternary ammonia concentration exceeding 500 parts-per-million (PPM), which is above the recommended level according to the manufacturer's instructions and the FDA Food Code. The Dietary Manager acknowledged the issue and indicated the need for vendor intervention to adjust the chemical dispensing assembly. Additional observations included the interior stainless steel retention plate of the ice machine, which was heavily stained and corroded with rust scale deposits. The can opener assembly and mounting plate bracket were found to be heavily soiled with encrusted food residue, and the cutting blade was blackened with excessive buildup. The coffee machine's interior and exterior surfaces were also soiled with accumulated and encrusted food residue. Furthermore, the commercial microwave oven's exterior door handle was cracked, broken, and could be rotated completely, indicating a lack of proper maintenance. Record reviews of facility policies revealed that there are established procedures for sanitation inspections and manual warewashing, which require all food service areas and equipment to be kept clean, sanitary, and in good repair. However, interviews with the Dietary Manager indicated uncertainty regarding the specific policies and procedures for cleaning and maintaining food service equipment, suggesting a gap between policy and practice. No information was provided about any residents' medical history or condition at the time of the deficiency.
Failure to Maintain Sanitary and Functional Environment Due to Inadequate Cleaning and Drain Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. Observations revealed that six out of nine PTAC unit filters in the first floor Main Dining Room were heavily soiled with accumulated and encrusted dust and dirt deposits, and the cabinet surfaces of these units were also dirty. Additionally, the flooring surface in the same dining area was found to be soiled with dust, dirt, and food residue. Staffing interviews indicated that the housekeeping department had ten housekeepers in total, with only one housekeeper assigned to the second shift, and three housekeepers covering call-offs and days off. Further investigation into the facility's maintenance practices uncovered ongoing issues with the food production kitchen floor drain, which was reported to flood randomly, sometimes daily or weekly. The Corporate Life Safety and Maintenance/Environmental Director confirmed a history of wastewater issues dating back nine years and described a reactive approach to drain maintenance, including snaking drains as needed and periodic cleaning of grease traps and wastewater lines. Review of the facility's policy on sewage and waste disposal indicated a requirement for maintaining free-running sewer lines and outlined steps for addressing blockages, but the observed conditions and staff interviews demonstrated lapses in effective implementation.
Failure to Document and Communicate Transfer/Discharge Information
Penalty
Summary
The facility failed to document complete transfer and discharge information for one resident who was reviewed for the transfer/discharge process. The resident, who had multiple diagnoses including paraplegia and a recent surgical repair of a fractured right femur, was admitted to the facility and later transferred to another long-term care facility after returning from the hospital. The electronic health record contained a progress note indicating the transfer, but there was no transfer form to the hospital, no discharge plan, summary note, or progress notes to indicate that instructions had been given to the receiving hospital or LTC facility regarding the resident's ongoing healthcare needs. Interviews with the DON and NHA confirmed that there was no transfer or discharge summary for the resident, and that the required information had not been provided to the receiving healthcare providers. The facility's own policies require that transfer/discharge notices and discharge planning documentation be completed and communicated to the resident, their representative, and the receiving provider, but these steps were not documented in this case.
Failure to Reconcile Controlled Drugs in Back-Up Box
Penalty
Summary
The facility failed to maintain a proper record of receipt, disposition, or reconciliation of controlled drugs in its back-up box, which is a secured storage unit for controlled drugs. During an observation, it was noted that the narcotic drawer lacked a plastic lock, indicating it had been opened after the pharmacy delivered a fully restocked narcotic supply. There was no documentation available to indicate when the pharmacy last delivered the back-up box or when narcotics had been removed. A sheet of paper with multiple undated entries showed that narcotics had been removed, with the last dated entry being 31 days prior. Upon inspection, discrepancies were found in the number of tablets present compared to what should have been available according to the dispensing sheets. The Director of Nursing (DON) was unable to explain the facility's process for narcotic reconciliation or the use of plastic locks on the narcotic drawer. The facility's pharmacist confirmed that the pharmacy delivers a fully stocked back-up box weekly with a numbered plastic lock. However, discrepancies were noted in the number of narcotics present versus what was recorded on the dispensing sheets. The pharmacist could not account for these discrepancies and mentioned that they only have the dispensing forms faxed by the nursing staff. The facility's Pharmacy Services policy requires a system of medication records for accurate reconciliation and accounting for all controlled medications, but this was not adhered to, leading to potential drug diversion and unavailability of controlled drugs for residents as prescribed.
Delayed Response to Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely action and communication regarding Medication Regimen Review (MRR) recommendations for two residents, resulting in the continuation of unnecessary medications. For one resident, the pharmacist recommended reducing or discontinuing sliding scale insulin due to its inefficiency and potential risks, as per AMDA guidelines and the American Geriatric Society's Beers Criteria. Despite the pharmacist's recommendation on multiple occasions, the physician did not review the recommendation until several months later, leading to a delay in addressing the medication regimen. For another resident, the pharmacist recommended discontinuing or specifying the duration for the PRN use of Xanax, in accordance with federal guidelines. However, the physician did not respond to these recommendations over two consecutive months. The Director of Nursing acknowledged the delay in physician response, noting that the expectation is for irregularity reports to be addressed within 30 days. This lack of timely communication and action between the pharmacist and physician contributed to the deficiency in medication management for the residents involved.
Medication Error in Antibiotic Eye Drop Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when only two doses of an antibiotic eye solution were administered out of the 56 doses prescribed. This resulted in the potential for prolonged signs and symptoms of a right eye infection. The resident, who had a history of a stroke, dysphagia, and a ruptured right eye, was observed with a sunken right eye and dried yellow crust on the eyelids. The resident's family member reported that the right eye infection had improved with less drainage than before. The resident's Electronic Health Record indicated a physician's order for erythromycin ophthalmic solution to be administered every four hours, but the Medication Administration Record showed that the resident only received the medication twice on one day. The Nurse Practitioner confirmed that the order was for a 14-day course of the antibiotic eye drops, but the orders were transcribed incorrectly on the MAR, leading to the resident not receiving the full course of treatment. The Director of Nursing acknowledged the transcription error, stating that the resident should have received the eye drops for 14 days.
Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to maintain a complete and accurate Antibiotic Stewardship Program, which resulted in a deficiency related to the monitoring and administration of antibiotics for a resident with an eye infection. The Infection Control Nurse (IFC) was unaware of the resident's prescription for Erythromycin ophthalmic solution for bacterial conjunctivitis, as the resident was not listed on the infection report log for November 2024. This oversight occurred despite the facility's protocol to document residents prescribed antibiotics on the infection report log for monitoring. The IFC nurse acknowledged that the resident's antibiotic usage was not documented or monitored, leading to an administration error. The resident's Electronic Health Record (EHR) indicated that they were prescribed Erythromycin ophthalmic solution for 14 days, but the Medication Administration Record (MAR) showed that the resident only received two doses on the first day. The Nurse Practitioner clarified that the order was for the eye drops to be administered four times a day for 14 days, but this was not followed. The IFC nurse admitted to not being notified of the prescription and recognized that if the antibiotic had been included in the infection report, the administration error might have been avoided. The facility's Infection Prevention and Control Program outlines the need for an antibiotic stewardship program, but the lack of documentation and monitoring led to this deficiency.
Deficiency in Influenza Vaccination Program
Penalty
Summary
The facility failed to consistently screen, educate, offer, and administer influenza vaccines to five residents, resulting in a deficiency. Resident R57 consented to receive the influenza vaccine, but there was no documentation in the Electronic Health Record (EHR) to confirm the administration of the vaccine. The Infection Control Nurse (IFC) D and the Corporate Clinical Director, RN Q, acknowledged the absence of evidence supporting the administration of the vaccine, despite the facility having the vaccine available. For residents R4, R9, R40, and R52, the facility did not complete the necessary documentation to indicate whether these residents were screened, educated, or offered the influenza vaccine. The consent forms for these residents were incomplete, undated, and lacked necessary signatures. In particular, R9 and R52, who had legal guardians, did not have documentation showing that their guardians were contacted or educated about the vaccine. RN Q acknowledged the invalidity of these incomplete forms. The facility's Infection Prevention and Control Program policy states that residents should be offered the influenza vaccine annually and provided with education regarding the benefits and potential side effects. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and incomplete consent forms for the residents reviewed. This failure to follow established procedures resulted in a deficiency in the facility's vaccination program.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment on the third floor, affecting 25 residents. Observations revealed cracked and chipped floor tiles, broken resident equipment, and a persistent malodorous smell. Additional issues included detached aluminum tape on air conditioning units, visible dirt and food particles on floors, broken hand sanitizer dispensers, missing window blind slots, and rusted bed frames. Interviews with the Housekeeping/Laundry Director and Environmental Director indicated that while there was a cleaning schedule, there was no evidence of monitoring by management, and the third floor was the last to be renovated with no known timeframe. On the fifth and second floors, the facility also failed to maintain cleanliness and repair, increasing the likelihood of cross-contamination and bacterial harborage. Observations included non-working lights in an elevator, a strong urine odor with stained baseboards, dingy and scratched hallway paint, and damaged wheelchairs for two residents. The Director of Maintenance and Regional Director of Maintenance noted these issues during a tour, and the Nursing Home Administrator acknowledged that cleaning and maintenance were ongoing processes, but the maintenance checklist lacked specific entries related to these concerns.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of medication administration in three instances. Firstly, an LPN did not prime an insulin pen before administering 35 units of Lantus insulin to a resident, which is against the manufacturer's guidelines and the facility's policy. Priming is necessary to remove air bubbles from the insulin reservoir to ensure the correct dosage is delivered. The LPN was unaware of the priming process, indicating a lack of training or understanding of the procedure. Secondly, the same LPN administered seven medications through a PEG tube to another resident without individually crushing and flushing each medication, contrary to the facility's policy. This practice can affect the efficacy and safety of the medications. Lastly, a transcription error was identified in the medication administration record for an anti-hypertensive medication, Metoprolol Tartrate, prescribed to the same resident. The error involved a misrecorded dosage, which was not clarified until 25 administrations later, despite the resident receiving the correct dosage. The Director of Nursing acknowledged the transcription error and the delay in its correction.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate hair care and grooming for three residents, resulting in unmet hygiene needs and emotional distress. One resident, who was receiving hospice care, was observed with unkempt hair that was matted and contained lint. The resident's family expressed concern about the lack of grooming, noting that the resident's hair had not been combed or washed for some time. The resident was severely impaired in cognitive skills and required assistance with activities of daily living (ADLs). Another resident was observed with tangled hair in a knotted ponytail, secured with a broken rubber band. This resident, who had contracted hands and required assistance with feeding, confirmed that staff did not comb or brush her hair. The resident was moderately impaired in cognitive skills and required supervision for decision-making, as well as assistance with ADLs due to various medical conditions. A third resident, who was legally blind, was observed with a visible beard and soiled clothing. This resident required supervision and assistance with ADLs due to impaired vision and mobility. Interviews with staff revealed confusion about who was responsible for grooming, with some believing it was the responsibility of the hospice company or the Activity Department. However, the Activity Director confirmed that no requests for grooming services had been made for the residents on the third floor.
Inadequate Supra-Pubic Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate supra-pubic catheter care for a resident, resulting in discomfort at the insertion site and the potential for catheter dislodgment and urinary tract infection. Observations revealed that the catheter tubing was taut and not properly secured, with the collection bag often positioned at the level of the bladder rather than below it. The resident expressed discomfort and noted that the catheter had been dislodged before, requiring hospital intervention. The insertion site was observed to be slightly reddened with dried yellow crust, and there was no dressing or anchoring device in place. Interviews with staff indicated a lack of consistent catheter care, with a CNA deferring responsibility to the nurse and an LPN acknowledging the need for an anchoring device but failing to recall specific care actions taken. The resident's electronic health record and care plan outlined specific catheter care instructions, including securing the catheter and positioning the collection bag below the bladder, which were not consistently followed. A previous incident of catheter dislodgment was documented, highlighting ongoing issues with catheter management.
Failure to Justify PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to justify the use of a PRN antianxiety medication, Xanax, for a resident with a history of cerebral infarction, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. The resident, who had intact cognition, was prescribed Xanax with an open-ended end date, and there was no documentation of a 14-day stop date or a gradual dose reduction attempt in the Electronic Health Record (EHR). The care plan identified the resident as being at risk for adverse consequences related to psychotropic drug use, but there was no medical justification for continuing the Xanax past 14 days. Interviews with facility staff revealed that the visiting psychiatry group typically monitors psychotropic medications, but in this case, the oversight was missed. The Social Worker confirmed the lack of a gradual dose reduction attempt or rationale for continued PRN use past 14 days. The Director of Nursing acknowledged that the physician did not respond to the pharmacist's irregularity report and failed to document justification for the continued use of Xanax. The expectation was for the visiting psychiatry group to monitor these medications, but they did not address the resident's Xanax prescription.
Lack of Coordination in Hospice Services Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was admitted with multiple diagnoses including acute respiratory disease and severe cognitive impairment, was under hospice care. However, the facility did not maintain adequate records of hospice services, as evidenced by the absence of nursing notes or visitations in the hospice logbook. This lack of documentation hindered the facility's ability to coordinate and communicate effectively with hospice staff. During the survey, it was discovered that the hospice notebook only contained a schedule of visitations from the social worker, chaplain, and nurse aide, but no notes from the nurse. The Corporate Consultant later confirmed that the hospice company was contacted to provide the missing nurses' notes, which should have been included in the resident's electronic medical record after each visit. The Director of Nursing acknowledged the issue, indicating that staff should have been communicating with hospice staff on-site, but was unable to explain how coordination was possible without access to the nurse's documentation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents, resulting in potential transmission of infectious organisms. For one resident, staff members, including a CNA, RN, and Wound Care Coordinator, were observed providing care without wearing PPE, despite the resident having a stage IV pressure ulcer and a history of sepsis and bacteriuria. Interviews revealed that staff were aware of enhanced barrier precautions but did not follow them, and there was no signage on the resident's door to indicate the need for PPE. The Director of Nursing acknowledged the need for retraining, and the Nursing Home Administrator confirmed that staff understood the precautions but did not implement them. For another resident with a PEG tube and recent diagnosis of bacterial conjunctivitis, CNAs and an LPN were observed providing care without wearing gowns, despite a sign in the hallway indicating the need for enhanced barrier precautions. The CNAs and LPN were unaware of the specific PPE requirements for residents on enhanced barrier precautions. The Director of Nursing stated that staff had been educated on proper PPE use, but the observations indicated a lack of adherence to the facility's policy on enhanced barrier precautions.
Call Light System Malfunction on Third Floor
Penalty
Summary
The facility failed to ensure that the call light system was properly functioning on one of its units, specifically the third floor, which resulted in a potential delay in responding to residents' care needs. During an observation, it was noted that residents were using assorted bells in their rooms instead of the standard call light system. One resident, who was alert and oriented, was unsure of the bell's location and mentioned going to the nursing station when in need of assistance. Another resident confirmed that the bells were provided because the call lights were not working, and sometimes the nurses could not hear the bells if they were down the hall. The Director of Maintenance (DM) reported that the issue began after an incident where an irate resident damaged the main box at the nursing station, leading to the malfunction of the call light system. The residents had been using the bells for approximately three weeks. Although the facility had obtained an undated estimated invoice for updating the nurse's call system on the third floor, there was no evidence of a signed contract or a plan for initiating or completing the repairs. The Administrator mentioned that the third floor was the last to be renovated, but no additional information regarding the timeline for the renovation was provided.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to review or revise the care plans for two residents following multiple falls, which is a deficiency in their fall prevention program. Resident R701, who was admitted with a fracture of the lower end of the right tibia and a pressure ulcer of the left heel, experienced falls on four separate occasions. Despite these incidents, the care plan interventions for R701 had not been updated since November 8, 2023, indicating a lack of timely response to the resident's changing needs. R701 also had impaired cognition and required assistance with bed mobility and transfers, which were not adequately addressed in the care plan updates. Similarly, Resident R704, who was admitted with cerebral infarction and epilepsy, experienced a fall on August 28, 2024. The review revealed that R704 had two fall care plans, one of which had not been updated since July 13, 2021, and the other lacked interventions to minimize the risk of additional falls. R704 also had impaired cognition and required assistance with bed mobility and transfers. The Director of Nursing acknowledged that the care plan should be updated with an intervention when a fall occurs, as per the facility's Fall Prevention Program policy, but this was not done for these residents.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as R702, who was at risk for falls. On the specified date, R702 was observed alone in their room, seated in a wheelchair, with a fall mat placed beside the bed. The resident's medical record indicated diagnoses of dysphagia and a brain disorder, with a cognitive impairment score of 2/15 on the Brief Interview for Mental Status, requiring assistance with bed mobility and transfers. The fall care plan, initiated on June 10, 2024, included the use of a concave mattress as an intervention. However, upon inspection, the Director of Nursing confirmed that R702's mattress was a regular one, not concave, as required by the care plan. The DON, new to the role, was unaware of the discrepancy and acknowledged the need for the correct mattress.
Failure to Monitor Resident Weights and Nutritional Status
Penalty
Summary
The facility failed to implement interventions to obtain resident weights for two residents who refused to be weighed, resulting in significant weight changes going undetected. Resident 902, diagnosed with Alzheimer's disease, had not been weighed since March 6, 2024, and was found to have lost 29.7 lbs (16.3% weight loss) over two months. The resident's dietary progress notes and care plans had not been updated or revised since early 2023, and no nutritional assessments had been completed since August 3, 2023. The facility did not document any nutritional interventions or assessments for Resident 902 from January 2024 to May 14, 2024, despite the significant weight loss observed by a family member and confirmed by staff on May 15, 2024. Resident 903, who is morbidly obese and a dialysis patient, had refused to be weighed multiple times, with the last recorded weight on February 17, 2024, showing 266.1 lbs. The resident's weight was documented as 305 lbs on May 13, 2024, indicating a 14.6% weight gain. Despite the availability of weight records from the dialysis center, the facility did not use this information to monitor the resident's weight. Nutritional assessments for Resident 903 were incomplete, missing critical information such as current weight, BMI, and weight status. The dietary care plans for Resident 903 had not been reviewed or revised since February 28, 2024. Interviews with the Director of Nursing, Registered Dietician B, and Corporate Registered Dietician C revealed that the facility's policy required monthly weight monitoring and nutritional assessments on admission, quarterly, and with significant changes. However, these protocols were not followed for Residents 902 and 903. The facility failed to notify physicians or the interdisciplinary team about the residents' refusal to be weighed, and no alternative assessment tools were used to evaluate their nutritional status. The lack of proper documentation and follow-up led to significant weight changes in both residents going unaddressed.
Failure to Prevent Fall and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement necessary interventions and provide adequate staffing to prevent falls, resulting in a serious incident involving a resident identified as R921. R921, a hospice patient with a history of stroke and right-side weakness, was found unresponsive on the floor with a pool of blood around the head. Despite being identified as 'not at risk' for falls in a previous assessment, the resident's care plan did not address fall prevention, and a floor mat intervention was not in place at the time of the incident. The incident occurred during a period of staffing shortages, as reported by LPN A, who noted that the facility was short-staffed on the day of the incident. LPN B, who worked the night shift, was responsible for two floors with only one aide, which was below the usual staffing level. This staffing issue contributed to inadequate supervision, as LPN B had to manage multiple responsibilities, including attending to a wanderer and problematic call lights, which may have limited the ability to monitor R921 effectively. The facility's fall prevention policy was not adequately followed, as evidenced by the lack of a fall risk indicator on R921's care plan and the absence of a floor mat. The policy required routine rounding and specific interventions for residents at risk of falls, which were not implemented for R921. The lack of adherence to the fall prevention program and insufficient staffing levels were significant factors leading to the incident, highlighting deficiencies in the facility's ability to provide a safe environment for its residents.
Non-Functional Call System in Resident Rooms and Shower Areas
Penalty
Summary
The facility failed to provide a functional call system for residents, particularly affecting those on the 2nd floor and in rooms 215, 307, and 312, as well as the shower rooms on the 2nd, 3rd, and 4th floors. During facility rounds, it was observed that there was no call light panel at the nurse's station to notify staff of resident needs. A nurse on duty was unaware of the missing panel, and call lights in specific rooms were found to be non-functional. Two residents reported their call lights had been non-operational for over two weeks, while another resident mentioned their call light had not worked for nearly six months, forcing them to call out for help or go to the doorway to seek assistance. Further environmental rounds with a corporate life safety support staff member revealed that the call lights in the shower rooms were not functional due to missing pull cords and non-functional alerts. These issues were confirmed during testing. Despite a request for call light audit logs from December 2023 to April 2024, the facility failed to provide them. The staff member responsible for life safety support admitted to not checking the maintenance logs during monthly rounds and acknowledged that unresolved maintenance concerns should have been addressed promptly. An interview with the facility administrator confirmed awareness of the call light issues and the lack of maintenance follow-up. The facility's policy on call lights emphasized the importance of ensuring accessibility and timely response, yet the policy was not effectively implemented. The absence of functional call lights and the failure to maintain audit logs indicate a significant oversight in ensuring resident safety and communication needs.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, staff, and the public, as evidenced by multiple deficiencies observed during a survey. The surveyor noted missing handrails in the elevator, malfunctioning elevator lights, and a delay in the elevator door closing, which had been ongoing for months. Additionally, there were widespread issues with gnats in various rooms and common areas, missing insulation around PTAC units, non-functional electrical outlets, broken blinds, and missing clocks in resident rooms. These deficiencies affected the living conditions and satisfaction of all 97 residents. Further observations revealed significant maintenance issues, including broken bedside tables, missing or broken tiles in shower rooms, and non-functional shower facilities on the 5th floor, forcing staff to use other floors for resident showers. The maintenance logs on multiple floors showed numerous unresolved entries, some dating back several months, indicating a lack of timely response to maintenance concerns. These unresolved issues included non-working heaters, leaking ceilings, sparking AC units, and broken blinds, among others. Interviews with staff, including a corporate life safety support staff member and the facility administrator, highlighted a breakdown in the process for notifying and resolving maintenance concerns. The maintenance personnel were expected to conduct daily rounds and address issues promptly, but this was not happening effectively. The facility's document titled 'Safe and Home Like Environment' outlined the expectations for maintaining a safe and comfortable environment, but the observed conditions fell short of these standards.
Inconsistent Resident Council Meetings and Lack of Documentation
Penalty
Summary
The facility failed to consistently assist the Resident Council in organizing and conducting monthly meetings, as well as in promptly addressing and resolving concerns raised by the council. Multiple complaints were received by the State Agency regarding issues such as long call light wait times and concerns with the facility's physical environment. Upon request, the facility administrator and DON were unable to provide resident council meeting minutes or follow-up documentation from November 2023 to April 2024. The Activities Director, who was new to the role, reported that they had scheduled future meetings but had no records for the requested period. An interview with the Resident Council president revealed that meetings were inconsistent, and there were insufficient chairs for representatives, with some sitting on milk crates. The facility's policy supports the rights of residents to organize and participate in resident groups, with the Resident Council meeting at least quarterly. However, the facility did not adhere to this policy, as evidenced by the lack of meeting minutes and follow-up documentation. The administrator acknowledged the absence of records and mentioned a new team and plan in place, but this did not address the deficiency during the survey period.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to promptly and thoroughly investigate allegations of abuse and neglect, including an injury of unknown origin, for several residents. Specifically, a hospice patient was found unresponsive on the floor with a serious head injury, and the facility did not conduct a timely investigation. The Facility Reported Incident (FRI) was submitted late, and the investigation report was incomplete, lacking staff interviews and record reviews. The Director of Nursing (DON) was absent during the initial days following the incident, and no other nurse manager initiated an investigation in their absence. Additionally, the facility did not comply with its policy or regulatory requirements for other incidents involving allegations of abuse between residents. The facility's policy mandates immediate investigation and reporting of such incidents, but the investigations were delayed, and reports were submitted late to the State Agency. The Nursing Home Administrator acknowledged these deficiencies, indicating a failure to adhere to the facility's procedures for handling allegations of abuse and neglect.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to follow up on grievances expressed by two residents, resulting in frustration and ongoing communication concerns. One resident, who was admitted with diagnoses including major depressive disorder and heart failure, reported missing personal belongings that were taken to the laundry. Despite speaking with several staff members over two weeks, the resident received no follow-up, leading to frustration. Another long-term resident, with conditions such as heart failure and diabetic neuropathy, expressed concerns about call light wait times, staff not checking blood pressure before administering medications, and being taken to another floor for showers. This resident also reported making staff aware of these concerns. The facility's grievance policy states that grievances should be resolved within five days, and the administrator acknowledged the need to review and follow the facility's policy. However, the facility did not provide grievance forms or evidence of follow-up for the two residents. The administrator, who was new to the facility, mentioned maintaining resolved grievance forms in a binder for review during Quality Assurance and Process Improvement meetings. The facility's policy emphasizes the right of residents and family members to voice grievances without fear of reprisal and outlines the responsibilities of the Grievance Official in overseeing the grievance process.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin involving a hospice patient, identified as R921, to the Nursing Home Administrator and the State Agency. The incident occurred on 4/10/24 when R921 was found unresponsive on the floor with bleeding around the head and no vital signs. Despite the serious nature of the injury, the Facility Reported Incident was not submitted to the State Agency until 4/12/24, two days after the occurrence. The Nursing Home Administrator acknowledged the delay in reporting and attributed it to not being made aware of the full details until later. The facility's policy on 'Abuse, Neglect, and Exploitation' requires that all alleged violations involving serious bodily injury be reported immediately, but not later than two hours after the allegation is made. In this case, the policy was not followed, as the report was delayed beyond the specified timeframe. The Nursing Home Administrator admitted that the staff should have reported the injury immediately as an injury of unknown source, indicating a lapse in adherence to the facility's reporting procedures.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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